Treatment of Attachment Issues

Written by Mark Schwartz, Sc.D

The primary treatment modalities for eating disordered clients typically are symptom focused, re-feeding, control of binge/purge cycles, challenging body checking and so on.  However the relapse rates are extremely high (Fairburn, 2005), and most experienced clinicians recognize that symptom control is only the first phase of treatment.  Once establishing sobriety and healthy food intake, the client typically experiences a flood of anxiety and fears in situations that were previously without difficulty.  The next step is sequential “exposure” to situations in which they establish mastery through their efforts and accomplishment.  See Table 1.

If all of this seems overwhelming it explains  why recovery is a process taking years; a catch-up of missed developmental experiences.  All of these structural capacities can be facilitated through attunement and a secure attachment with the therapist.  The critical requisite is enjoying the process as opposed to experiencing massive anxiety related to the goals.

CREATING SECURE ATTACHMENT

If secure attachment was unchangeable following childhood, the power of psychotherapy would be limited and a general gloom surrounding healing from early hard-wiring of painful experiences and neglect would exist.  Mary Main’s concept of “earned secure attachment” is therefore, of great interest to clinicians.  One of the characteristics of earned secure attachment on the Adult Attachment Assessment is meta-cognitional thinking, also called mentalizing (Fonagy et al, 1996).  It involves the ability to reflect on one’s mental states, elaborating a theory of one’s mind, decentralizing, and thereby establishing a sense of mastery and personal efficacy (Ardovini, 2001).  This meta-cognitional ability in psychotherapy allows the individual to feel safe deconstructing childhood events, cognitions, affective responses and reconsidering conclusions then and now.  Impaired mentalization is quite obviously a central psychopathological feature of eating disordered clients.  The anorexic concretization of control and predictability in life’s emotions can be described as one of the most difficult components of change (Skarderud, 2007).  In Fonagy’s (1996) research, the eating disordered clients scored lower on mentalization together with patients diagnosed as borderline personality, from all other psychiatric patients.  The eating disordered individual has a deep pervasive feeling of unreliability concerning their ability to decode inner states; therefore, they utilize others to know what they should feel.  Preoccupation with bodily qualities, sensations and distortions in perceiving one’s own body and others obviously reflects impaired mentalization.  Obviously the therapist’s capacity to relate and appropriately attune to the client is critical (particularly the concept that “what is thought is felt,” meaning bodily realities reflect emotional realities – lack of control equals body expansion).  Interpreting the bodily sensations in reference to loss of control, vulnerability, distrust, sense of ineffectiveness, affect tolerance and dysregulation and contradictory cognitions, need for purity and so on can be most critical – that is interpreting and mirroring bodily states into emotional, cognitive and relational experience.  Unable to accept rejection or other’s criticism is equated with rejecting one’s body fat.  Accepting rejection becomes critical to defining a cohesive self.

Another major roadblock is that eating disordered clients may perceive others mainly as deceitful and intrusive. This causes an even greater dependency on the primary attachment figure.  As the individual begins to experience disappointment in the primary relationship, there is disequilibrium and the beginning of discovering self-competence.  If they overeat or purge they see themselves as totally unable to control their impulses.  Unable to trust self and their primary attachment figure may result in a temporary overdependence on the new secure attachment with the therapist, requiring a loosening of boundaries slightly since “availability” may be equal to “caring.”  Certainly, discussion of boundaries becomes essential, particular how the eating disordered clients perceive therapist actions.

Critical to developing mentalization is a coherent family history from different family members.  In order to contextualize meanings related to experiences, perceived, remembered, and actual truths.  In family therapy, the parents are encouraged to de-idealize themselves and mentalize by exposing their legacies,  lifelong conflicts, and states of mind.  They reflect on their feelings, expectations and failings allowing reconsiderations related to their failings from over-control of intrusiveness,  over rewarding of dependency, or goal oriented and instrumental successes.

The path is then laid to renegotiate boundaries with family, develop a family of choice of friends and become more “self-led,” as defined by Richard Schwartz, Ph.D.  This includes Internal Family System’s  “C’ words: calmness, curiosity, clarity, compassion, confidence, courage, and connectedness.  The client learns to turn to self and others for self-soothing and real intimacy (as opposed to false self pseudo intimacy).  The therapist uses the therapeutic relationship to allow for tolerating, modulating, interpreting and communicating affective states and to allow for mastery of feared experiences and relationships. Integrating affect into experiences and strengthening narrative competency allows for greater mentalization capacity.  The therapist also facilitates learning of new skills around affect tolerance, problem solving, interpersonal effectiveness, social skills, dating skills, maintaining boundaries and recognizing natural intuitiveness without disqualification, playing and recreation, labeling emotions, and body mindfulness.

Table 1

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